癫痫外科脑电图和神经电生理技术标准

癫痫外科术前评估和术中监测包括一系列多学科合作项目,长程视频脑电图(VEEG)监测是术前评估中最重要的内容之一,有些患者还需要进一步颅内放置电极后进行长程VEEG监测.术中皮质脑电图(ECoG)也常用于癫痫外科.在涉及到运动功能区时,术中诱发电位监测可有效保护运动功能.在接受癫痫外科手术后的数年内,需要定期复查VEEG...     

脑磁图累积源成像在药物难治性颞叶癫痫术前评估中的应用

目的 探讨脑磁图累积源成像(MEG)在难治性颞叶癫痫术前评估中的应用价值.方法 回归分析法2006年1月至2018年1月手术治疗的11例难治性颞叶癫痫临床资料.使用MRI、长程视频脑电图、MEG以及颅内电极脑电图(IEEG)帮助定位致痫灶并制定手术方案,术后随访1年,按Engel分级评估疗效.结果 MRI无明显异常5例...     

额叶癫癎发作的癫癎灶定位

目的 通过分析40例额叶癫痫发作患者术前定位的临床资料，探讨额叶癫痫发作的癫痫灶综合定位方法。方法 应用临床发作症状评估、MRI／CT扫描、单光子发射计算机体层摄影术(SPECT)检查、长程视频脑电图监测以及颅内电极记录等方法综合定位额叶癫痫患者的癫痫灶。结果 应用非侵袭性检查可以为45．0％的患者进行额叶癫痫灶定位；结合颅内脑电图长程记录，癫痫灶定位率可达90．0％；当影像学检查阴性时，78．9％的患者可以定位癫痫灶。结论 应用临床发作症状学评估、影像学检查、长程视频脑电图监测以及颅内脑电图长程记录相结合的综合定位方法，可以显著提高额叶癫痫发作的癫痫灶定位效果。     

长程视频脑电图监测期间不良事件及应对措施研究

长程视频脑电图（Video-electroencephalogram,VEEG）监测是用于癫痫诊断、癫痫分类和癫痫手术术前评估的一种有价值的工具。患者在癫痫监测单元也存在着一些诸如跌伤、发作持续状态等不良事件的风险,但对监测过程中的不良事件及处理方法缺乏统一的标准。为了提高长程视频脑电图监测质量,减少患者在监测过程中可能受到的伤害,需要对监测过程中可能出现的不良事件及应对措施进行总结。     

难治性颞叶癫痫的手术治疗方式及其疗效研究

目的 探讨难治性颞叶癫痫的临床特点、术前评估方法、手术治疗方式及其疗效。方法 105例难治性颞叶癫痫患者术前行头部CT及MRI检查,同时加行双侧海马磁共振波谱分析(MRS);并均行长程视频脑电图检查。根据患者的术前临床发作特点、影像学和长程视频脑电图检查结果,在术中皮层脑电图监测下行手术治疗。术后随访患者1年以上,观察手术的疗效。结果 本组患者中,48例海马硬化患者行前颞叶切除术(包括大部分海马及杏仁核);另外57例有其他病灶的患者先行病灶切除术,复查皮层脑电图其中23例患者仍有异常放电,对这23例患者加行前颞叶切除术(包括大部分海马及杏仁核),前颞叶切除后有5例患者仍有异常放电,予以皮层热灼术。手术疗效:术后80例患者的癫痫发作完全消失,13例患者较术前明显缓解,12例患者无明显变化;总有效率为88. 6%,优良率为76. 2%。结论 颞叶癫痫的发作形式有一定的临床定位价值,如果患者的神经影像学和视频脑电图检查结果一致,则强烈建议手术治疗。手术一定要在皮层脑电图监测下进行;同时术中在切除颞叶病变后,应根据皮层脑电图监测结果加行前颞叶切除术,必要时再加行皮层热灼术,以解决双重病理现象。     

长程颅内电极监测定位技术在癫痫外科中的应用(附19例临床分析)

目的分析长程颅内电极对难治性癫痫患者的癫痫发作起源区定位作用,评估采用这一技术后的癫痫发作控制以及手术并发症的发生情况。方法19例难治性癫痫患者,采用常规脑电图及其它检查不能明确癫痫发作起源区位置,或癫痫发作起源区与重要功能区关系密切,对怀疑脑区进行颅内电极埋置术,术后进行长程颅内脑电监测,根据脑电情况,确定发作起源区,明确与功能区的部位后,进行切除术或多处软膜下横切术。结果19例患者中,核磁共振有双侧病变者5例,单侧病变9例,核磁共振阴性的患者5例。非侵袭性的术前评估方法结论不一致的有11例。手术后15例患者发作消失,3例患者发作频率减少90%以上,1例癫痫发作控制无效。1例患者发生永久性局限视野缺损,缺损为左上视野区,1例患者电极埋置术后出现一过性失语,切除术后未发生失语。结论对于采用常规脑电图及其它检查不能明确癫痫发作起源区位置,或癫痫发作起源区与重要功能区关系密切的患者,长程颅内脑电图监测能够准确定位发作起源区位置,回避功能皮质区,有效降低并发症的发生率。     

长程脑电对癫痫外科术前定位的价值

目的 本研究为了确定长程脑电监测在癫痫外科术前定位、定侧作用。方法 对４０例顽固性癫痫患者进行术前普通脑电图（ＲＥＥＧ）、长程动态脑电图（ＡＥＥＧ）及术中皮质电图（ＥＣｏＧ）进行比较研究。结果 发现长程脑电监测对癫痫诊断的异常率、癫痫灶的定位率及手术定位率明显高于常规脑电图。但ＡＥＥＧ对精确定位不十分准确,结合术中皮质脑电图描记可以提供准确的手术部位和范围。结论 癫痫外科术前如有条件应该用长程脑电     

婴幼儿期灾难性癫痫的术前评估

目的探讨婴幼儿灾难性癫痫的术前评估及其与手术方式的选择和预后的关系。方法对我院癫痫中心2000年以来收治的28例婴幼儿期灾难性癫痫患者进行临床资料回顾性分析和评估,患儿术前均接受了长程视频脑电图和影像学等各项评估检查。结果按照Engel分级和常规神经外科分级对手术效果进行评价。本组无手术死亡病例,随访3个月至3年,90%以上经手术治疗的患儿术后疗效满意或症状显著改善。而拒绝手术的患儿药物治疗效果不佳。结论对于婴幼儿灾难性癫痫,完善的术前评估是决定手术方式和手术治疗效果的关键。     

难治性枕叶癫痫的术前定位与手术治疗

目的探讨难治性枕叶癫痫的术前定位与手术方法。方法对经手术治疗且随访时间6个月以上的9例枕叶癫痫患者的临床资料进行回顾性分析。采用发作症状评估、影像学检查、长程视频头皮脑电图监测、颅内电极脑电图记录等方法综合术前定位。根据术前定位确定的致痫灶部位与范围采用不同的手术方法。7例病人采用颅内电极置入术来精确定位。局部枕叶皮层切除2例,枕叶大部或全部切除4例,全枕叶或后头部脑叶离断3例;同期经枕入路切除或离断颞叶内结结构3例。结果术后随访6个月至2年,术后癫痫无发作6例,发作1次1例,发作减少90%以上2例。结论难治性枕叶癫痫经手术治疗可以取得较好的疗效,颅内电极脑电图记录有助于致痫灶准确定位,并指导术中切除部位与功能保护。     

脑电定位与手术治疗难治性癫痫疗效观察

目的 探讨难治性癫痫的术前、术中脑电图定位方法及手术疗效.方法 对621例难治性癫痫患者采用普通脑电图监测(REEG)、长程脑电图监测(AEEG)、视频脑电图监测(VEEG),结合患者病史特点及影像学结果进行综合定位;术中在皮层脑电图(ECoG)监测下依据脑电图定位及不同发作类型选择适合术式切除致痫灶,并观察术后疗效.结果 术后随访6月至4年,满意(术后无发作)340例,占55%;显著改善(发作减少＞75%)223例,占36%;良好(发作减少50%～75%)37例,占6%;效差(发作减少＜50%)21例,占3%;无加重病例;有效率达97%.结论 以脑电图监测为基本手段,采用综合定位的方法结合术中ECoG监测明确癫痫灶的部位和范围以指导手术,能有效防止并发症的发生,并取得良好的治疗效果.     

Bilateral mesial temporal lobe epilepsy: comparison of scalp EEG and hippocampal MRI-T2 relaxometry

OBJECTIVE: Bilateral hippocampal abnormality is frequent in mesial temporal lobe sclerosis and might affect outcome in epilepsy surgery. The objective of this study was to compare the lateralization of interictal and ictal scalp EEG with MRI T2 relaxometry. MATERIAL AND METHODS: Forty-nine consecutive patients with intractable mesial temporal lobe epilepsy (MTLE) were studied with scalp EEG/video monitoring and MRI T2 relaxometry. RESULTS: Bilateral prolongation of hippocampal T2 time was significantly associated with following bitemporal scalp EEG changes: (i) in ictal EEG left and right temporal EEG seizure onsets in different seizures, or, after regionalized EEG onset, evolution of an independent ictal EEG over the contralateral temporal lobe (left and right temporal asynchronous frequencies or lateralization switch; P = 0.002); (ii) in interictal EEG both left and right temporal interictal slowing (P = 0.007). Bitemporal T2 changes were not, however, associated with bitemporal interictal epileptiform discharges (IED). Lateralization of bilateral asymmetric or unilateral abnormal T2 findings were associated with initial regionalization of the ictal EEG in all but one patient (P < 0.005), with lateralization of IED in all patients (P < 0.005), and with scalp EEG slowing in 28 (82,4%) of 34 patients (P = 0.007). CONCLUSION: Our data suggest that EEG seizure propagation is more closely related to hippocampal T2 abnormalities than IED. Interictal and ictal scalp EEG, including the recognition of ictal propagation patterns, and MRI T2 relaxometry can help to identify patients with bitemporal damage in MTLE. Further studies are needed to estimate the impact of bilateral EEG and MRI abnormal findings on the surgical outcome.     

Clinical and ictal characteristics of infantile seizures: EEG correlation via long-term video EEG monitoring

Purpose

The semiology of infantile seizures often shows different characteristics from that of adults. We performed this study to describe clinical and ictal characteristics of infantile seizures at less than two years of age.

Methods

A retrospective study was done for infants with epilepsy (ages: 1–24 months) who underwent long-term video electroencephalography (EEG) monitoring at Samsung medical center between November 1994 and February 2012. We analyzed the clinical and ictal characteristics of the 56 cases from 51 patients.

Results

In 69% of the patients, the seizure onset was before six months of age and the etiology was symptomatic in one third of the patients. Twelve seizure types were identified; spasms (24%), unilateral motor seizures (18%), and generalized tonic seizures (15%) were the three frequent types of seizure.All partial seizures were well correlated with the partial-onset ictal EEG, however 19.4% (7/36) of clinically generalized seizures revealed partial-onset ictal EEG. About one-thirds (4/11) of generalized tonic seizures had its ictal onset on unilateral or bilateral frontal areas and two out of seven generalized myoclonic seizures showed unilateral frontal rhythmic activities. Hypomotor seizures mainly arose from the temporal areas and hypermotor seizures from the frontal regions.

Conclusions

Even though most of the seizure semiology of infants is well correlated with ictal EEG, some of the generalized tonic seizures or myoclonic seizures revealed partial-onset ictal EEG suggesting localized epileptic focus. Accurate definition of seizures via video EEG monitoring is necessary for proper management of seizures in infancy, especially in some clinically generalized seizures.     

额叶癫痫发作录像脑电图特点分析

目的通过录像脑电图观察额叶癫痫的临床特征、发作期及发作间歇期的脑电图特点。方法使用录像脑电图（ｖｉｄｅｏＥＥＧ,ＶＥＥＧ）对５０例确诊为额叶癫痫的患者进行常规及长时间记录,对其中１７例（２０次）癫痫发作的临床表现及脑电图所见进行分析。结果额叶癫痫常见的发作形式有：姿势性发作,具有额叶癫痫特点的自动症;复杂部分性发作时伴发声、偏转或表情的变化,有时出现发作性情绪改变或强迫思维等少见症状。其发作特点为：持续时间短,发作相对较频繁,无明显发作后意识障碍。发作间歇期脑电图有时可无阳性所见,典型的临床发作及发作时ＶＥＥＧ记录到的额部爆发性节律有助于诊断。本组９例儿童期起病的额叶癫痫患者,以夜间频繁的躯体自动症发作为主,检查均未发现相应的脑器质性病变。脑电图睡眠描记可见频繁的额部导联癫痫样放电。临床治疗观察预后良好,提示可能为一组儿童原发性部分发作型癫痫综合征。结论额叶癫痫是一组较为特征性的癫痫综合征,临床并不少见,及时而正确的诊断有助于治疗。     

Lack of aura experience correlates with bitemporal dysfunction in mesial temporal lobe epilepsy

The diagnostic value of lack of aura experience in patients with temporal lobe epilepsy (TLE) is unclear. PURPOSE: To evaluate possible factors of bitemporal dysfunction in patients with mesial TLE who did not experience an aura in electroencephalography EEG/video monitoring for epilepsy surgery. METHODS: Ictal scalp EEG propagation patterns of 347 seizures of 58 patients with mesial temporal lobe sclerosis or non-lesional mesial TLE, interictal epileptiform discharges (IED), presence of unilateral mesial temporal lobe sclerosis in visual magnetic resonance imaging (MRI) analysis, prose memory performance, history or not of an aura, and postictal memory or absence of an aura were analyzed. The ictal EEG was categorized as follows. EEG seizure: (a) remaining regionalized, (b) non-lateralized, (c) showing later switch of lateralization or bitemporal asynchronous ictal patterns. RESULTS: Absent aura in monitoring was significantly correlated with absence of unitemporal MRI sclerosis (P=0.004), bitemporal IED (P=0.008), and propagation of the ictal EEG to the contralateral temporal lobe (P=0.001). Other historical data and interictal prose memory performance were not significantly correlated with absent aura. Ten of 11 patients without aura in monitoring also had absent or rare auras in their history. CONCLUSIONS: Lack of aura experience strongly correlates with indicators of bitemporal dysfunction such as bitemporal interictal sharp waves and bitemporal ictal propagation in scalp EEG, and absence of lateralized MRI sclerosis in patients with mesial TLE. The fact that absent auras are not correlated with episodic memory suggests a transient memory deficit, probably because of rapid propagation to the contralateral mesial temporal lobe.     

Interictal, unifocal spikes in refractory extratemporal epilepsy predict ictal origin and postsurgical outcome.

OBJECTIVES: To evaluate the significance of exclusively unifocal, unilateral, interictal epileptiform patterns on scalp electroencephalography (EEG) in surgical candidates with medically intractable extratemporal epilepsy. METHODS: We reviewed 126 patients with refractory extratemporal partial seizures who underwent epilepsy surgery at our center. All were followed for at least 2 years after resections. Surgery was based on ictal EEG recordings. We examined ictal onsets and surgical outcome in subjects whose preoperative, interictal scalp EEGs during long-term monitoring (LTM) demonstrated only unilateral, well-defined focal discharges, and outcome in patients whose interictal EEGs during LTM showed bilateral, non-localized, or multifocal epileptiform patterns. RESULTS: We found that 26 subjects exhibited only unilateral, unifocal, interictal epileptiform patterns. In all 26 cases (100%) clinical seizures arose from the regions expected by the interictal findings (P<0.0001, Sign test). At last follow-up 77% (20/26) of these patients were seizure-free, while 23% (6/26) had >75% reduction in seizures. This compares to the remaining patients, of whom 34% (34/100) were seizure-free, 41% (41/100) had >75% reduction in seizures, and 25% (25/100) had <75% reduction in seizures (P=0.0001, Fisher's Exact test). CONCLUSIONS: Strictly unifocal, interictal epileptiform patterns on scalp EEG, though seen in a minority of subjects, may be an important, independent factor in evaluating subjects with intractable extratemporal, localization-related epilepsy for surgical therapy. This finding is highly predictive of both ictal onsets and successful postsurgical outcome.     

Epilepsy in severely handicapped children

Clinical and electroencephalographic studies were performed to elucidate the characteristics of epilepsy in severely handicapped children. The subjects were 56 severely mentally and physically handicapped children whose ictal seizures were documented by simultaneous EEG-VTR monitoring. Seizure types were infantile spasms in 17 (30.4%), atypical absence in 5 (8.9%), myoclonic seizures in 3 (5.4%), generalized tonic-clonic seizures in 2 (3.6%), secondary generalized partial seizures in 11 (19.6%), and undetermined in 4 (7.1%). Epilepsy types were also classified by the ictal seizure types and clinical courses: West syndrome in 27 (48.1%), Lennox-Gastaut syndrome (LGS) (at onset) in 5 (8.9%), partial epilepsy in 13 (23.2%) and others (at onset) in 11 (19.8%). Among 29 cases with West syndrome, 22 (81%) developed LGS, and among 11 cases with others group, 64% developed LGS. After all, LGS appeared in 60.7% of all 56 severe epileptic children associated with severe physical and mental handicaps.     

Clinical correlations of occipital epileptiform discharges in children.

OBJECTIVES: To determine the frequency of different causes of occipital epileptiform discharges (OEDs) in children and to analyze the EEG features that help predict epilepsy type and prognosis. METHODS: We identified children with OEDs in the absence of other focal discharges using an EEG database at our center; the presence of generalized spike-wave discharges (GSW) or slowing was not an exclusion criterion. Diagnosis, neurologic status, seizure semiology, and seizure remission status were recorded. RESULTS: Of 90 patients with OEDs, 50 (56%) had symptomatic seizures (18 with cerebral palsy, 11 with cerebral dysgenesis, 8 with genetic abnormalities); 31 (34%) had idiopathic seizures, including 6 with benign childhood epilepsy with occipital paroxysms (BCEOP), 8 (9%) had no seizures; and 1 (1%) had febrile seizures. Only two reported ictal visual symptoms. Eighty-seven percent with background slowing had symptomatic seizures, and 87% with normal backgrounds had idiopathic seizures (p < 0.001). Of 72 children with seizures and adequate follow-up, 28 of 45 (62%) with a normal background experienced seizure remission compared with 10 of 27 (37%) with background slowing (p = 0.04). Twenty of 81 patients with epilepsy had GSW. Twelve (60%) of the 20 GSW-positive patients had idiopathic epilepsy compared with 19 of 61 (31%) without GSW (p = 0.02). CONCLUSIONS: Most epilepsy in referred children with OEDs is symptomatic; syndromes such as BCEOP are rare. Visual ictal symptoms are rare. The presence of GSW or a normal background rhythm correlates with idiopathic seizures and a better prognosis.     

Postoperative routine EEG correlates with long-term seizure outcome after epilepsy surgery.

We investigated the correlation of interictal epileptiform discharges (IED) in routine EEG 6 and 24 months after epilepsy surgery with regard to long-term seizure outcome. In 148 patients (74% temporal lobe epilepsy (TLE), 26% extratemporal epilepsy) EEG results (IED present or absent) were correlated with the postoperative outcome using the Engel classification 6 and 24 months after resection (PO6m and PO2y, respectively). Self-evaluation was conducted 3 and 5 years after resection (PO3y and PO5y, respectively). Ninety-one patients (62%) were seizure-free 5 years after resection; 88% of them showed no IED in PO6m. Twenty-eight patients (19%) displayed IED in routine EEG 6 months after resection; 61% of them had recurrent seizures at PO5y, whereas of 120 patients without IED only 33% had recurrent seizures at PO5y; p=0.01. Absence of IED in PO6m and PO2y correlated with good outcome: 71% without IED remained seizure-free, whereas only 25% with IED at PO6m and PO2y remained seizure-free; p=0.001. Seizure-free patients (Engel 1) and patients with less favourable outcome (Engel 3-4) at PO6m and PO2y rarely changed categories of outcome during the following years (p<0.001). Half of the patients with favourable seizure reduction (Engel 2) changed to seizure-free (Engel 1) or to a worse outcome category (Engel 3-4). Postoperative routine EEG is a good prognostic instrument for the prediction of long-term seizure outcome, especially for TLE. It predicts the running up and down of fits in patients with rare seizures (Engel 2).     

Panayiotopoulos-type benign childhood occipital epilepsy: a prospective study

OBJECTIVE: To characterize the clinical and EEG features of the syndrome of benign childhood partial seizures with ictal vomiting and EEG occipital spikes (Panayiotopoulos syndrome [PS]). METHODS: Prospective study of children with normal general and neurologic examinations who had seizures with ictal vomiting and EEG with occipital spikes. RESULTS: From February 1990 to 1997, the authors found 66 patients with PS and 145 children with benign childhood epilepsy with centrotemporal spikes. Peak age at onset of PS was 5 years. Ictal deviation of the eyes and progression to generalized seizures were common. One-third had partial status epilepticus. During sleep, all had seizures. While awake, one-third also had seizures. Five children with PS had concurrent symptoms of rolandic epilepsy and another five developed rolandic seizures after remission of PS. Prognosis was excellent: one-third had a single seizure, one-half had two to five seizures, and only 4.5% had frequent seizures. CONCLUSIONS: Panayiotopoulos-type benign childhood occipital epilepsy is less common than benign childhood epilepsy with centrotemporal spikes but is well defined and recognizable by clinical and EEG features.     

Clinical implications of scalp ictal EEG pattern in patients with temporal lobe epilepsy

ObjectiveTo determine the clinical implications of scalp ictal EEG pattern in patients with temporal lobe epilepsy (TLE).MethodsScalp EEG ictal patterns were retrospectively determined in 27 consecutive patients with medically refractory temporal lobe epilepsy who underwent phase-1 scalp video-EEG and phase-2 simultaneous scalp and intracranial video-EEG recordings for pre-surgical evaluation.ResultsOf the 192 temporal lobe seizures recorded during phase-1 and phase-2 scalp video-EEG studies, 124 (65%) seizures were associated with theta/alpha (5–9 Hz) ictal onset pattern, and 68 (35%) seizures were associated with delta (2–5 Hz) ictal onset pattern. Fourteen (52%) patients had exclusively theta/alpha ictal onset, 3 (11%) patients had exclusively delta ictal onset, and 10 (37%) patients had mixed theta/alpha and delta ictal onsets. MTLE was observed in 26 patients who had 124 seizures with theta/alpha ictal onset and 59 seizures with delta ictal onset. LTLE was observed in one patient who had 9 seizures with delta ictal onset. Scalp ictal EEG pattern was not significantly correlated with postsurgical seizure outcomes.ConclusionsBoth scalp delta and theta/alpha ictal onset patterns can be commonly found in patients with MTLE.SignificanceScalp delta ictal onset is not a unique EEG pattern for LTLE as commonly believed.